Chapter 16

### Definition of the Complaint

Children refuse to walk because of pain, neuromuscular weakness, and certain mechanical factors. The list of possible etiologies in this regard is very extensive, consisting of both benign and life-threatening conditions. A systematic approach examining these causes is necessary to ensure a comprehensive evaluation.

A normal gait is a ”smooth, mechanical process that advances the center of gravity with a minimum expenditure of energy.” The stance phase is the time period when the heel strikes the ground bearing the individual’s weight and the ball of the other foot leaves the ground. This requires very strong abductor muscles to stabilize the pelvis. In addition, the swing phase is defined as the time when the foot leaves the ground until the next heel strike.

There are many types of abnormal walking patterns. An antalgic gait is the pattern adopted to minimize pain. With this pattern, the patient will shorten the stance or weight-bearing phase on the affected limb, thereby minimizing the amount of time exerted on the painful limb. This will also result in a shortened stride length. A patient with a fracture, soft tissue injury, or infection, will use an antalgic gait. Circumduction is the pattern followed to shorten a limb and improve limb clearance. This is commonly seen when there is excessive joint stiffness secondary to spasticity or a leg-length discrepancy. A Trendelberg gait is when the muscles on one side of the pelvis are weak causing pelvic instability; when both sides are involved a waddling gait is observed. An unsteady gait is suggestive of the presence of ataxia. A steppage gait is seen in cases of peripheral neurologic weakness. The foot slaps the ground as the patient walks due to decreased ankle dorsiflexion.

### Complaint by Cause and Frequency

When a child refuses to walk the most common causes may vary based on a child’s age (Table 16-1). The primary causes of limp, such as pain, weakness, and mechanical factors, can be further grouped by the following mechanisms: trauma, infectious, inflammatory, congenital, developmental, neurologic, neoplastic, hematologic, metabolic, and nonorganic (Table 16-2).

Table 16-1. Common Causes of Refusal to Walk in Childhood by Age.
Table 16-2. Causes of Abnormal Gait in Childhood by Mechanism.

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